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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004457
Report Date: 08/02/2021
Date Signed: 08/02/2021 03:25:15 PM

Document Has Been Signed on 08/02/2021 03:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MASSA, SHAYNA L.FACILITY NUMBER:
384004457
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
08/02/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Shayna MassaTIME COMPLETED:
03:50 PM
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Licensing Program Analysts (LPA) Mok conducted a Pre-licensing inspection with an applicant, Shayna Messa, today. Applicant's children were present. The applicant applied for a Family Child Care Home License on 7/6/2021. The applicant rents a single family house with 7 bedrooms, 4 bathrooms, 3 kitchens, living room, and backyard. The applicant lives with her husband, her 2 children, and her nephew in the house. Her nephew’s girlfriend will move into the house in 3 weeks. LPA discussed with the applicant about the fingerprint clearance and TB test have to be completed before she moves in. The daycare is located on the ground level. The daycare area is the entire ground level except an applicant’s office . The off-limit areas are the entire first and second levels, and backyard. LPA inspected the facility for health and safety hazards. The applicant had plenty of age-appropriate toys, books, learning material & equipment, and children's furniture available for children. The applicant also installed child-proof knobs to the door of the office . There was a fully charged 2A10BC fire extinguisher and working smoke and carbon monoxide detectors in the unit. All electrical outlets were covered in the daycare areas. All sharp corners were covered. Playpens and cots were available for napping. The children's bathroom was clean. The lower bathroom cabinet was free of dangerous items. The lower kitchen drawers and cabinets were either latched or free of harmful objects. The applicant had a current CPR/First Aid Certificate & Mandated Reporter Training. LPA discussed baby bouncers, baby walkers, exersaucer, Nap Nanny, Napping Portable, and other similar items are not allowed in daycare areas with the applicant. LPA also discussed with the applicant about Immunization for staff during the inspection. LPA also discussed IMS with the applicant. A sample of the IMS was provided to the applicant during the inspection. Incidental Medical Services (IMS) policy was discussed. For IMS information, see Evaluator Manual - regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to the publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm. LPA provided a copy of the IMS to the applicant as a sample during the inspection. LPA discussed the new Safe Sleep Regulations. LPA also discussed A child Care Provider’s Guide to Safe Sleep and left a copy of the handout with the applicant during the inspection. The applicant should have the Thermometer, hand sanitizer, & disinfectant available in the house to prevent COVID19. The hand sanitizer and disinfectant must be stored in a higher place to prevent children's access to them.

The following items have to be completed before licensure:
· The fingerprint clearance for all adults.
· a copy of the nephew's girlfriend TB test result with her full name on it.
· Criminal Record Statement ( LIC 508) for her nephew’s girlfriend.

LPA provided and explained a list of Records to be Maintain in the facility with the applicant to use for all children in care. This report will be kept in the facility file and shall be made available for public review upon request. Website for forms and regulations: www.ccld.ca.gov.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Cindy Mok
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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